What's davintosh? Mostly just the random ramblings of a hopelessly distractible… Hey, what's that?

Robotic-Assisted Laparoscopic Partial Nephrectomy

Filed under: Cool Technology,Medical Adventures — dave @ 11:00 am 2013/12/15

That right there is a load of $20 words, but it’s just a fancy way of saying “cutting a chunk out of the kidney without the doctor having to stick his hands in in your side.” It also describes some pretty cool technology, and it’s what they call the procedure that I’ll be going through tomorrow. But before I get into that, a quick (and belated) update on what’s happened since my last post is in order…

I checked in at the Sanford Surgical Tower (no idea why it’s called a tower; it’s not) on October 22 for the biopsy on my kidney tumor, and the procedure went very smoothly. The results came in two days later; the tumor is just a run-of-the-mill renal cell carcinoma, and can be removed surgically. That was a big relief; the thought of another round of chemo and radiation was more than I wanted to think about. I could handle it, with God’s help and that of great friends & family and an even greater wife, but if I had my druthers… Nope. I did a happy dance when I got the news!

So with that news in my back pocket, we met with the surgeon, Dr. Ahrend, a few weeks ago to discuss the next step; surgery. The urologist I spoke with first, Dr. Hofer, said that I was a good candidate for robotic laparoscopic surgery instead of “open surgery”; open surgery for a nephrectomy, partial or full, involves an incision that follows the bottom of the ribcage from the chest around to the back, half way around the torso. That was the way they did things in the days before laparoscopy, and what they still do with some patients that don’t meet the physical requirements for a laparoscopic procedure. The surgeon needs full access to the kidney, and that just isn’t possible without a huge entry point like that. The beauty of laparoscopy, and robotic laparoscopy in particular, is that the surgeon can get that full access to the organ without having to make an incision big enough to see through and to get a pair of big mitts into. Laparoscopy lets the doc manipulate tools inside the patient while watching what’s going on by way of a video feed a pair of miniature cameras. Adding the robotic angle to it makes it almost like climbing right inside…

Dr. Ahrend is a pretty young guy (as can be seen in this KELO news bit) but he is also the best guy in the business in Sioux Falls. He’s done over 700 robotic procedures since residency, and makes it sound like mine will be somewhat routine. While chatting with him at the end of our appointment, he commented that he likes to tell his mom, “all those video games are finally paying off,” and that is a good (but not great) description of how he does the laparoscopic nephrectomy with the assistance of a pair of robotic “hands.”

The “robotic” part is a little misleading though; that term has connotations of the process happening somewhat autonomously, and this machine is anything but automatic. It’s more of a bionic surgery by remote control. The history of the procedure is pretty cool; I’m told it originated with the military, with the idea that a patient who was wounded on the front line could be operated on without having to be transported far, and the surgeon could work from a safe place far from the front line. So far it hasn’t been used in that capacity, but there has been at least one procedure done over a long distance; the surgeon was in New York and the patient in Strasbourg, Germany. The big problem that can keep something like that is latency, the amount of time it takes for a signal to get from the controller to the robotics and the return trip for whatever kind of feedback signal is used. Apparently it was acceptable in this experiment, and in a normal procedure where the surgeon is in the same room as the patient, it’s seldom a problem, but that’s the sort of thing that would keep a networking guy up all night.

When doing a robotic procedure like this, the surgeon has a stereoscopic view of things through a video feed from a pair of cameras that are inserted into the area being worked on. The console that he works from has a pair of video monitors with a divider down the middle to give the surgeon a 3-dimensional view of what’s going on inside; depth perception in the surgical site is crucial.

The tools that are used are remotely manipulated by the surgeon using specialized controllers in the console; much more sophisticated than any joystick or video game controller, because what’s being controlled is much more sophisticated than anything in any shoot-em-up/crash-em-up video game. And the stakes are much, much higher than any video game.

Notice the scale of the little scissor tool in the hand of the model, then watch the video below; the surgeon’s hand movements are scaled down while his view of the surgical site are magnified so that he has a better view of things and a higher degree of control over the tools he’s using.

This YouTube video is pretty fascinating to watch, as it gives a view of exactly what the surgeon sees through his live video feed, and lets you see the dexterity of the robotic tools. It’s especially interesting because the case is very similar to my own; a male patient in his 50′s with a 2 centimeter mass on the upper quadrant of the right kidney. The video is not for the faint of stomach, as you see all the blood and gore and cutting and yuck, but it’s very informative for the same reasons. You’ve been warned!

Watching the video doesn’t give one a very good idea of how things are arranged for the surgery and where on the body the incisions are made. I’m told they make five incisions for the tools to be inserted, and from the photos & videos I’ve seen they go in from all directions. It would be interesting to attend a robotic surgery while conscious to see exactly how it’s set up and done.
Another pretty cool tool that Dr. Ahrend will be using is Firefly Fluorescence Imaging technology. With Firefly, a dye is injected into the bloodstream during surgery, and when a black light is used to illuminate the surgical site, normal tissue will fluoresce bright green, while cancerous tissue appears dark. Under normal lighting conditions it’s difficult to tell the difference between normal and cancerous tissues; the contrast that results with the Firefly dye and black light helps the surgeon know with a higher degree of certainty that all of the cancerous tissue has been removed. They also use ultrasound to help delineate the boundaries of the tumor, but adding Firefly to the surgeon’s tool belt helps immensely in making sure they get all of the tumor the first time, and don’t remove any more kidney tissue than is absolotely necessary.

Here’s another video from the Shawnee Mission Medical Center that demonstrates the use of Firefly, and gives a great demonstration of what happens before the surgeon starts digging around inside, and a good view of some of the equipment used.

That brings us to today, the day before surgery. All in all, I’m pretty relaxed about the whole thing. It’s a little weird (scary weird) seeing all of that and knowing it’s what they’ll be doing to me tomorrow, but I’m ok with it. After all I’ve learned about the procedure, it’s easy to forget how new this whole robotic thing is, but the doctor’s confidence in it is pretty contagious. And knowing that I don’t have to deal with the aftermath of open surgery is huge!

My biggest comfort in all of this though is knowing how many people are praying for us. It’s really a humbling thing being on the receiving end of all that, but the prayers really do make a difference. I am extremely grateful for each and every person lifting us up, and for their concern for us. God is faithful, and I trust that he will see us through this. As for the recovery, I’m really looking forward to some time off; I’m taking two weeks of medical leave from work. It seems like such a long time since I’ve had any time off from work where I wasn’t busy ahead of time getting ready for going somewhere. This time I’ll just be at home, resting. For now though the waiting is the hardest part. Nothing like a bit of anxiety over the procedure, mixed with fasting from everything but clear liquids for the 24 hours leading up to it, plus an enema waiting for me tomorrow morning. It’s gonna be a Monday like no other.

I’m actually looking forward to getting this surgery done and out of the way. I may be speaking too soon, but I think the surgery and recovery will be a walk in the park compared to chemo and radiation. The thing I’m really looking forward to is hearing the news that I’m cancer-free. That will be worthy of a celebration!


Here are some other links that I found to be of interest when researching this topic. Again, many of them show actual surgical procedures, so click with caution.

Information on kidney cancer
News4 da Vinci partial nephrectomy with Firefly
HD Robotic Partial Nephrectomy using “Firefly” Fluorescence Technology
Firefly Fluorescence Robotic Surgery With da Vinci
Robotic Partial Nephrectomy performed by Vipul Patel, MD

Happy Birthday Dr. Who, Plus A Bunch Of Jokes Really Fast

Filed under: Fun!,Geek — dave @ 10:16 am 2013/11/23

In commemoration of the fiftieth anniversary of the first airing of Dr. Who, here is a goofy Dalek joke from the Vlog brothers, mixed in with a bunch of other goofy jokes. I was too busy laughing (at some of them) to pay attention to the count… I’ll take his word for it there are 53. And some are quite good.

Also, gotta love Google’s Dr. Who doodle for today:

More Vlog Brothers’ Joke Videos: 31 Jokes for Nerds, 50 More Jokes, 50 Jokes in 4 Minutes and 50 Jokes.

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Listen, Smith Of The Heavens

Filed under: Faith & Worship,Fun! — dave @ 11:04 pm 2013/10/16

Can’t say I’ve ever heard Icelandic folk music before, but after hearing this beautiful song, sung a cappella (by the group Arstidir) in a cavernous subway in Germany, I think I’m hooked. Now I just need to learn a little Icelandic.

The song in the video is “Heyr Himna Smiður”. It was originally written as a poem by Kolbeinn Tumason in 1208, while on his deathbed (the story of his death is sad and tragic.) The melody that accompanies the text was written by Þorkell Sigurbjörnsson, over 700 years later. With a hat tip to the contributors at Wikipedia, “the original text is presented here with 19th-century Icelandic spelling and a rough, literal translation into English.” The translation is a beautiful psalm to the Lord God; it could’ve been penned by King David himself. But I have no doubt the poem is even more lyrical when spoken in the original language.

Heyr, himna smiður,
hvers skáldið biður.
Komi mjúk til mín
miskunnin þín.
Því heit eg á þig,
þú hefur skaptan mig.
Eg er þrællinn þinn,
þú ert drottinn minn.

Guð, heit eg á þig,
að þú græðir mig.
Minnst þú, mildingur, mín,
mest þurfum þín.
Ryð þú, röðla gramur,
ríklyndur og framur,
hölds hverri sorg
úr hjartaborg.

Gæt þú, mildingur, mín,
mest þurfum þín,
helzt hverja stund
á hölda grund.
Send þú, meyjar mögur,
málsefnin fögur,
öll er hjálp af þér,
í hjarta mér.

Listen, smith of the heavens,
what the poet asks.
May softly come unto me
thy mercy.
So I call on thee,
for thou hast created me.
I am thy slave,
thou art my Lord.

God, I call on thee
to heal me.
Remember me, mild one,*
Most we need thee.
Drive out, O king of suns,
generous and great,
every human sorrow
from the city of the heart.

Watch over me, mild one,
Most we need thee,
truly every moment
in the world of men.
send us, son of the virgin,
good causes,
all aid is from thee,
in my heart.

* or mild king. This is a pun on the word mildingur.

The Kidney

Filed under: Medical Adventures — dave @ 11:39 pm 2013/10/15

I have a mass on my right kidney, which was found somewhat accidentally during the diagnostic work done for the lymphoma in my jaw. That mass was assumed to be a typical renal cell carcinoma nodule. Treatment of renal cell carcinoma is usually pretty straightforward; partial or complete nephrectomy (removal of kidney tissue.) With that assumption, I went into the first meeting today with my urologist, Dr. Hofer, optimistic that being cancer free was just around the corner. Sure, getting there involved surgery, most likely a robotic-assisted laparoscopic partial nephrectomy, but compared to the chemotherapy and radiation therapy I’ve already been through, that should be a breeze. Relatively speaking, of course.

But, again the words “unusual” and “different” and “interesting” came up during the appointment. Dr. Hofer said my case would make a good trick question in a urologists’ exam. The curve ball that made him question the off-the-cuff diagnosis of renal cell carcinoma is the fact that I’ve already been treated for lymphoma, combined with what he saw in the PET scan; the mass just didn’t look like a typical renal cell carcinoma. He’s been doing this stuff for 20-plus years, and has seen a fair number of them, so he ought to know what they look like. He also said that lymphoma will occasionally grow on the kidney, and is easily mistaken for something else. But unlike renal cell carcinoma which is usually a contiguous mass and easily removed, lymphoma is more diffuse; surgical removal is less effective because the tumor’s boundaries aren’t well defined, and it often metastasizes to other organs.

So, given my history and the physical appearance of this particular mass, Dr. Hofer suggested performing a biopsy of the mass before diving in and cutting out a chunk of the kidney. If the biopsy shows that it is indeed renal cell carcinoma, then I’ll go back in for the partial nephrectomy. But if it turns out to be lymphoma, I will still have both my kidneys intact, and will go back to Dr. Bleeker and Sanford Oncology for more treatment. I’m not looking forward to that, but…

The biopsy will be done by one of the Sanford Radiology docs; they’ll use an ultrasound to guide a probe to the proper spot on my kidney to get a sample of the mass. Much less invasive than laparoscopic surgery, but will still require an overnight stay at the hospital. We don’t have a date just yet; should find that out tomorrow.

It’s a bit of a disappointment; here I thought I was a surgical procedure away from being done with this stuff, but now we’re faced with more questions and more diagnostics to try & get some answers.

BMWotD — ’95 540i M-Sport In The Best Color

Filed under: BMW Of The Day — Tags: , , , — dave @ 3:56 pm 2013/10/06

The e34 M-Sport 540i pushes a lot of the right buttons for me (I’ve drooled over them before) but this one is extra special, and the reason can be summed up in one word; Hellrot. Red cars just make me jiggy. The ’91 Dinan 535i Turbo that caught my eye a while back was nice, but this one, with all the M-Sport goodies. Mmmmm! Unfortunately, and as usual, the asking price for this one is way outside my price range, but a guy can dream.

1995 BMW 540i M-Sport Hellrot Red/M-Cloth Hurricane Manual Sedan
In late 1995, just prior to switching to the E39 5-series body style for the 1997 model year (there is no such thing as a U.S. 1996 model year 5-series), BMW pumped one last breath of life into the V8 powered, E34-bodied, 540i for the U.S. market: The 1995 540i M Sport.
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All Clear

Filed under: Medical Adventures — dave @ 8:25 am 2013/10/02

Wow; thought I hit publish on this one already. Now it’s old news (so I guess that would be “olds” instead of “news”?) I got some really good news from Sanford Oncology following the PET scan two weeks ago; the lymphoma in my jaw is gone!

I’m still not out of the woods, but it’s definitely a step in the right direction. There is still the mass in my kidney to be dealt with, so I have an appointment with a urologist in a couple of weeks to talk about the options for getting that removed (more on that when I know more.)

As for the lymphoma, since things are clear, I only need to return to the oncologist in three months for a checkup, then go back for another PET scan in six months.

Life is good. God is better.

Bushy-Tailed Tree Rats

Filed under: Cars!,The House — dave @ 8:29 am 2013/09/20

We only have a single-car garage, which typically doesn’t have room for even a single car, so parking a car or three on the street is pretty much normal at our house. Just down the street from our property there is a walnut tree between the curb and the sidewalk, not far from where the 528e is usually parked.

A couple of days ago I saw a squirrel run out from under that car, and something made me think that he hopped down from the underside of it… I didn’t give it much thought it at the time, but this morning, while driving that car to work, I heard a little ‘thump’ as I was slowing for a stoplight, then saw a green walnut go rolling along the curb into the intersection. Great.

Looks like I need to do some inspecting and see how many more nuts that bushy-tailed tree rat has squirreled away in my car. And how much damage he’s caused in the process.

The In-Between Time

Filed under: Medical Adventures — dave @ 12:50 pm 2013/09/12

It’s been a while since my last update, so I suppose I’m way overdue for another. Actually, this post was started weeks ago, but it never seems quite finished, and instead of just finishing it, I find myself going back to it again & again and revising big chunks of it. Even the post title has probably changed a half-dozen times… Probably not the most efficient way to get the job done, but… It may have ended up a little on the wordy side too; just a warning. Good thing I don’t charge by the hour or by the word.

My last post ended with the results of my second PET scan in late June. While the procedure was a little rough, it yielded some good news; we had gained some serious ground on the cancer in my jaw, and we were ready to roll into the next phase of treatment, radiation therapy. Those treatments weren’t much more fun than the last PET scan, and even now, seven weeks out from my last treatment, I’m still feeling the lingering side-effects. The positive side of this in between time is that I haven’t even seen the inside of a hospital, clinic or infusion center since July 25 (happy dance!) My next appointment is for blood work and a third PET scan on September 18, followed by a visit with my oncologist to go over the results. It’s been really good to not be picked on for a while after about 17 weeks of being poked, prodded, gouged, scanned, pumped full of toxins and and being irradiated by a linear accelerator. Recovery from the radiation seems to be much slower, but I’m finally starting to feel closer to normal (whatever that is; I think I forgot.)

To recap what has happened since that last scan…
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Ride The Booster

Filed under: Geek,Space,Travel — dave @ 7:25 am 2013/08/05

Stuff like this fascinates me. The video is made from actual footage from cameras that rode along on two different shuttle flights, and shows the view from one of the booster rockets. The sounds I think are artificial (added after the fact by Skywalker Sound) but still add a lot to the effect of the video.

Hat tip to Break.com (for this one, and lots of other entertaining posts!)

YouTube link

BMWotD — e36 Compact with M50 Six

Filed under: BMW Of The Day — dave @ 11:27 am 2013/07/26

It’s been a while since I last posted a BMWotD, and I’ve got a few of them stashed away on my local drive, so time to play some catch-up.

This one was listed for sale on the Minneapolis CraigsList earlier this month, and had (un)fortunately sold before I saw mention of it on the 318ti.org forum recently. Looks to be a nicely executed swap on a very clean car. Loving the interior on this car too. The asking price may have been a little on the high side, but the fun factor combined with the clean factor plus my favorite color would’ve made it hard to pass up. Good thing I didn’t have the chance to deliberate whether to take a shot at it.

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